HomeMy WebLinkAboutContract 47186-P11 CITY SECRETARY
CONTRACT NO.
I i-
ADDENDUM
To
BIackStone 504 Program
Provider Agreement
This Addendum is entered into by and among Richard Haenke, DO ("Member Prov er"), Rockport
Healthcare Groi}}p ("R okport"), and the City of port Worth ("City") on this day of
20 .
WI-MIZEAS,Rockport and Member Provider entered into a Provider Agreement,effective December 1,
2,010, ("Provider Agreement"), and desire that this Addendum apply to covered services that are
governed bythe Texas Insurance Code,Texas Labor Code,and Texas Administrative Code,
1WHBIMAS, Rockport has contraoted with Member Provider on behalf of the City in the process of
setting up a direct contracted 504 provider panel pursuant to Texas Labor.Code Section 504,053,
WHERBAS,the City has determined that a workers'compensation health cafe network certified tinder
Texas Insurance Code Chapter 1305 Is not available or practical for its self-insured worker's'
compensation prograin needs and,as such,have eleoted to provide medical benefits to Injured workers by
directly contracting with health care providers,
WHEREAS, Rockport, Member Provider, and the City desire to execute this Addendum in order to
establish a direct contract between Member Provider and the City under Texas Labor Code Subsection
504,053(b)(2),
WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions of the Provider
Agreement to be the same terms and conditions that apply to the direct contrast between Member
Provider and the City that make available covered services for Qualified Participants'needs to the injured
workers of the City.
NOW,TREREF01%for good and valuable consideration,the sufficiency and receipt of which is hereby
acknowledged,the parties agree as follows:
1, All terms and conditions ofthe Provider Agreement are hereby adopted by both Member Provider
and the City, with full consent and agreement of Rockport, to apply as a direct contractual
agreement between Member Provider and the City,All references to certified networks as well as
the Texas Insurance Code, Chapter 1305 and Sections 408.023, 408.027, and 413,041 of the
Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set up under
section 504.053 of the Texas Labor Code. The City's Provider Manual (under the name of
Blackstone) shall instead apply to matters of notice, billing, dispute resolution, complaints,
preauthorization,and xelated matters.
2• The parties agree that the City will bear the financial responsibility for payment to Member Provider
under the terms of the Provider Agreement subject to the applicable Provider Manual and the
provisions of the Texas Labor Code and applicable rules under the Texas Administrative Code.
Rockport will continue to provide applicable network administrative services.
3. When used!it this Addendum,unless the content otherwise clearly requires,-the following words and
terms shall have the meaning sat forth below, Ali other defined terms shall have the meaning
ascribed to them in the Provider Agreement.
R ORD
M WOfi"
Richard Haenko,DO Provider Agreement
'Tayors"will be the City as they are responsible for payment of medical benefits for
compensable injuries and or illnesses sustained by its injured workers according to the
Texas Workers CompensationAot,
`91ackStone"is the 504 Provider Panel established by the City of)?ort Worth through
this and other direct contracts using Rockport as its contracting agent
"Provider Manual"mcans the Blackstone Provider Manual as amended from time to time
and available upon request to the Member Provider.
"Provider Panels"are those direct contracted panels formed by political subdivisions or
publio pool entities authorized by Section 504.053 of the Texas Labor Code.
4. Member Provider agrees to participate in the 13lackStone provider panel for the benefit of the City
' and Qualited Participants,
5, Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates a
new cause of action,
6, All other terms of the Provider Agreement shall remain in force and unchanged, Any_conflicts
between this Addendum and the Provider Agreement shall be superseded by the terms provided
herein.
IN'WITMi SS's a-WREOF,the parties hereto have executed this Addendum effective on the day and year
fast written above.
For and on behalf of:
City of Fort Worth
Blackstone
I
Signature: _
Name: Su air lanis
Title: Assistant City Manager
Date: c�
APP110VED AS TO FtaUA AND LEGALITY:
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OFFICIAL RECORD
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CITY SECRETARY
FT.WORTH,TX
Richard Hawke,DO Provider Agreement
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PHYSICIAN.AGREEMENT •`—
ROCKPORT HEALTHCARE GROUP,INC.
This Physician Agreement("Agreement"),is entered who desire to become a Member Provider with
into by and between Rockport Healthcare Group, RHG. , .
Inc., a Delaware Corporation ("RHG"), - its
subsidiaries Rockport Community Network; Inc. (a I:2 "Qualified Participant" means: (a) an employee,.
preferred provider organization. for -occupational member.and/or. dependent of an RHG,payor/client
injuries and illness), Newton Healthcare Network, who is eligible to receive certain healthcare benefits
Inc. LLC (a preferred provider organization for under an individual or group accident and health
group and individual health and personal injury benefit plan, personal injury protection plan, or any
protection), and Rockport Preferred, Inc. (a medical other insurance program; (b) a person who presents
sa ' gs : card) and with authorization from the Employer prior to the
�fGd/.4�2 ("Physician"), initiation oftreatment that the worker is currently-
and
urrently-and will become effective as of the date the employed and that the presenting problem was work
Agreement.is..executed.by.RHO. _ relatcd;_.either..in writing..or, by telephone;. and (c)
individuals and/or families eligible -to receive-
WHEREAS, RHG is. engaged in the business of contracted rates as described in Exhibit B by virtue
developing and acting in an administrative capacity of their verified participation in the Medical Access
in providing individual. and group accident and Savings Card Program,which is neither an insurance
health; occupational injury and illness; personal or benefit plan,
injury protection; and Medical Access Savings'Card
provider networks that offer a new integrated L3 "Payor" means an individual, organization, firm
.:continuum of healthcare services. or.governmental.entity, including but not limited to
an employer, .self-insured' employer, employer
WHEREAS, .Physician desires to provide medical coalition, health. insurance purchasing cooperative,.
care services to "Qualified Participants" who are insurer, third party administrator; or a Qualified
covered by Payor Agreements at the rates in Exhibit Participant in a Medical Access Savings Card
B; and Program. These Payors have entered into a Payor
Agreement with RHG for the provision of.
WHEREAS,RHG has entered intoAgreements with healthcare services to. . Qualified Participants and,
one or.more insurance carriers, self insured groups, have agreed to pay'for such services; pursuant to
and third party administrators to provide :for such Payor Agreement. .
healthcare review, medical service, bill review/cost
containment and other medical utilization.services 1.4 "mor Agreement" means. the agreement
for employers. between RHG and a Payor, which is made before,
on or after the effective date of this Agreement and . .
.NOW; THEREFORE, in .consideration of the which expresses the agreed upon contractual.rights
premises,the mutual promises contained herein, and and obligations of the parties:
other good andvaluable consideration, the receipt
and sufficiency of which are hereby acknowledged, 1.5 "Member Provider" means any physician;
it is mutually agreed as follows: physician group; hospital; surgery center; diagnostic,
imaging center; . laboratory; clinic; chiropractor;:
L DEFINITIONS dentist; podiatrist; psychologist; ..social worker; .
physical, occupationaland speech therapist; etc.
When used in this Agreement and unless the content licensed or certified to practice a healthcare
otherwise clearly requires, the following words and profession or licensed as a facility to offer healthcare
terms.shall mean: services, in the state where services are rendered,
who has met the credentialing requirements of RHG,
I.1 "Physician'means a licensed Medical Doctor or and who has been accepted by RHG as a,Member
Doctor of Osteopathic Medicine, or group of same Provider and who has executed a contract with
RHG.
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12/05/01 :.
I.6 "Primary Care Physician" means a Member I.11 `Bill and/or Claim Form"means a HCFA 1500
Provider who has met the cxedentialing requirements and/or UB 92 used for billing for all services with
of RHG to be a.Primary Care Physician and is regard to Accident-.and Health, Personal Injury
designated by RHG as a Primary Care Physician. Protection, and Occupational Injury and Illness
Plans. For services rendered to Qualified . -
I.7 "Specialist Physician" means a Member Provider. Participants of the Medical Access Savings Card
who has met the cxedentialing requirements of RHG Program, Member Provider can and should make
to bea Specialist Physician, and to.whom Primary payment arrangements priorto the delivery of care
Care Physicians. may refer for necessary and with the patient or responsible party. Services
authorized care other than primary care services. provided in connection with the use of the Medical-
Access Savings Card must be documented by a
1.8 "Emergency" means those health care services receipt that the Qualified Participant may use for tax
that are provided in a hospital emergency facility purposes or..in conjunction with other coverage.
after the .sudden onset of a medical condition Member Provider can pursue collection efforts
manifesting. ,itself. .by_, symptoms of sufficient . directly_ .with_ .these...Qualified Participants if
severity,including severe pain, such that the absence necessary. :. All others will be paid, when
of immediate medical attention could reasonably be appropriate,only after submission of a complete and
expected by a prudent layperson, possessing an accurate claim.
average knowledge of health and medicine , to result
.in: .(i) placing the Qualified Participant's health in H. PHYSICIAN OBLIGATIONS
serious jeopardy; (ii) serious impairment to bodily
functions; or (iii) serious dysfunction of any bodily. H.1 Services. Physician agrees to provide or arrange
.:organ or part. To the.maximum extent permitted by for all medically necessary health care for Qualified
.law, the determination of whether an Emergency Participants., who seek care from Physician.
existed at the time covered services were provided Physician agrees to perform such services withthe
shall be made exclusively by Payor. same standard of care, skill and diligence which is
customarily used by Physicians in the.community in
19 "Covered Services" are those healthcare and which such services are rendered. Physician agrees
health-related services as defined by each individual that it is his/her.sole responsibility to verify that the
benefit plan and state and/or federal rules and individual presenting for care is a Qualified
regulations. RHG will communicate Payor specific Participant: Physician agrees to render healthcare.
Covered :Services to each Member Provider. servicesto Qualified Participants in the same
Services covered under the Medical Access Savings manner, in accordance with the same standards, and
Card Program are not subject to this definition. with the same. time availability as offered to...
Physician's other patients. Physician shall ensure
I.10 "Utilization Review and Quality Assurance that services provided are consistent with.RHG's .
Pro am" means the program. or programs, pxograms,policies and procedures and the applicable
applicable to the Payor, with .the exception of Accident and Health; Personal Injury Protection,
Utilization Programs for .Qualified Participants in occupational injury and illness, Medical Access "
the Medical Access Savings Card Program, as Savings Card programs and plans. Physician agrees
amended from time _ to time, through which to comply with and be bound by all Benefit Plan
appropriate, cost-effective, utilization of health Designs, State/Federal rules. -and regulations,
resources is sought and utilization "and practice Utilization Review and Quality Assurance
patterns .are monitored in order to identify and, as Programs.
appropriate, to correct deviations from established
norms. Medical necessity and medically necessary II2 Non-Discrimination. Physician shall not
determinations are established and administered by differentiate or discriminate in the treatment. 'of
the Payor or the Payor's designee, in accordance his/her patients as to the quality of services delivered
with Exhibit A, with the exception of Qualified to Qualified Participants'because of race, sex, age,
Participants in the Medical Access Savings Card religion, national origin, place of residence, source'
Program. . of payment or health status. Physician shall observe,
Page 2 of 11 RHG Physician Agreementdoe
12/05/01
protect and promote the rights of Qualified Enforcement Administration("DEA")and/or various
Participants as patients. State Controlled Substance Registration Authorities.
IL3 Covering Physician. Physician agrees to devote 1I.6.2 Medical Staff Privileges.. Certain medical
such time as is necessary to the performance of specialties may not require hospital privileges such.
his/her obligations under this Agreement, including as Industrial and Occupational Medicine, Pathology,
maintaining reasonable office hours. Physician Dermatology, Allergy, etc. Where appropriate,
agrees to maintain accessibility either personally or Physicians must maintain active, unrestricted staff
by covering arrangements with another.'Member privileges with at least one RHG Member Provider
Provider of likespecialty or other qualified hospital or Surgery: Center. Physician . hereby
physician approved by RHG, on a twenty-four (24) consents to disclosure by such facility to RHG of alF
hour-per-day, seven (7), day-per-week basis. data collected with . respect. to Physician in
Physician shall ensure that such Member Provider or connection with Physician's: medical . staff
other physician shall comply with RHG's and each membership, including without. limitation. all
Payors Utilization Review and Quality Assurance applications for staff privileges and any renewals
Programs
-and._will:comply,.with Article IV.of this.,... _,thereof.
Agreement.
H.6.3 Organization's Requirements. Physician shall
11.4 Referrals. .Except in a medical emergency or comply with and be bound by RHG's criteria for
when authorized 'by RHG or its designated provider participation, including RHG's
representative, Physician agrees to refer Qualified administrative policies and procedures; as adopted
Participantsonly to other. Member Providers, as and amended from time to time.by RHG. Physician
defined in I.5, when medically necessary and shall cooperate with RHG's periodic evaluation of
appropriate.All referrals must be in accordance with: professional qualifications which shall include;.but.
the applicable Utilization Review and Quality not be limited to, Physician giving consent.to the
Assurance.Program unless specifically directed by release:of information from any facility at which
RHG. In addition,Physician agrees to use RHG's or Physician has medical staff privileges. In,addition,
the applicable Payors pharmaceutical formularies, if Physician shall cooperate .with RHG's ,and each
any,•when prescribingmedications for Qualified Payor's programs and procedures, as approved by
Participants. RHG,for the expeditious resolution of any grievance
or complaint.
11.5 Reports. For each.encounter where Physician
.provides. 'services to a Qualified Participant, II.7 Notification to RHG. Physician represents and
Physician shall report such encounter on an warrants that information provided herein and in the
appropriate form and shall: include statistical, RHG provider application is true and accurate in all
descriptive medical and.patient data and identifying respects and acknowledges that RHG.is relying on
information, if and to the extent that reports are the accuracy of such information in entering into and
specified by RHG or its designated representative. continuing the term of this agreement. Physician
shall notify RHG immediately upon becoming aware
II.6 Professional Requirements. of the initiation of any investigation, disciplinary
action, sanction, or peer review action against`
II.6.1. Licenses. Physician shall be duly licensedto Physician that could result in (i) suspension,
practice medicine in the state where care is rendered reduction or loss of license to practice Physician's
And hold _ such other - licenses, certifications, profession or. to provide healthcare services; (ii) . .
registrations, permits and approvals as_are required denial; suspension, restriction, reduction or..
for the lawful conduct of Physician's practice. termination of privileges or staff membership at any.
Evidence of such current -licensing and/or health facility or by any peer review.body; (iii)
certifications shall be submitted promptly to RHG. impairment of Physician's_ ability, to- provide
when data changes or renewal occurs and upon . healthcare services safely; or (iv) imposition of any
request. Physician will have, where appropriate, a sanction under the Medicare program or Medicaid
current narcotics number issued by the appropriate program. In addition, Physician shall provide prior . .
authority, currently the United States Drug written notice to RHG of any changes in (i) Federal
Page 3 of 11 RHG Physician Agreement.doc
12/05/01
Tax Identification Number, (ii) other information designated representative thereof, including . the
provided in his/her application.for participation, (iii) designated utilization review, quality management,
Physician's professional liability insurance, (iv) case management or peer review staff, to have
Physician's billing or office address,and(v) services reasonable access to treatment records and
provided by Physician. A failure to give any notice information of Qualified Participants for services
required by this Section shall be a material breach of provided under the terms of this Agreement as
Physician's obligations and responsibilities necessary to enable such party.to perform Utilization
hereunder, regardless of the status, pendency or Review and Quality Assurance activities in
outcome of the event giving rise to the obligation to accordance with the applicable Utilization Review
give that notice, and may be grounds for delay in and Quality Assurance Program. In addition,
payment, claim denial and/or immediate termination Physician agrees that in the event an examination "
of this Agreement. concerning the quality of healthcare services is
conducted by appropriate officials; as required,by
H.8 Medical Records. Physician shall maintain federal,state,and/or local law,RHG shall submit, in,
complete.and timely medical records for Qualified a timely fashion,any required books and records and
Participants treated by Physician. Such records.shall....... __shall.,:.facilitate, such..examination: RHG and
be prepared in accordance with accepted principles. Physician agree to assist one another.with on-site
of practice, shall document all services performed inspection of facilities and records by representatives
for Qualified Participants and shall comply with all of authorized federal, state and local regulatory
applicable state and federal laws. Physician shall agencies.
maintain such records for the length of time
required by applicable state or federal law. Subject IL 10 Relationship of Parties. Physician understands
to all applicable privacy and confidentiality and agrees that he/she is an independent legal entity.
requirements,. such medical records shall be made Nothing in this agreement shall be construed.or
available.- to each physician and other health deemed to create a relationship of employer and
professionals treating the Qualified Participant, and employee, principal and agent, partnership,or joint
upon request, to the Payor, RHG or its designated venture or any relationship other than that of
representative for review at no charge. Physician independent parties contracting with each other
shall obtain a'valid consent for the release of the solely to carry out the provisions of this Agreement
Qualified Participant's medical records to other for the purposes recited in this Agreement. With
providers, RHG, Payor,. or its designated regard to the provision of medical and healthcare
representative. RHG agrees that medical records of . services,Physician acts as an independent entity and
Qualified Participants shall be treated as confidential the Physician-patient relationship shall in no way be
so as to comply with all federal and state. laws and affected.
regulations regarding the confidentiality of patient
records. The Physician's obligations under this II.11 Standards of.Care.. Physician agrees that all
Section 11.8 shall survive the termination of.this duties performed hereunder shall be consistent with .
Agreement. the proper practice of medicine, and that such duties
shall be performed in accordance with the customary.
II.9 Inspection of Records and Operations.. RHG, rules of ethics and conduct of the American Medical
Payor, with the exception of Qualified Participants Association or American Osteopathic Association,
in the Medical Access Savings Card Program or a as the case may be, and such other bodies, formal or ,
designated representative, shall have the right to informal, government or otherwise, from which
inspect and audit, at all reasonable times during physicians seek advise and guidance or by which
normal business hours, upon prior notice, any of they are subject to, licensing/certification and
Physician's accounting, administrative, medical control. Additionally, Physician shall perform all
records and operations reasonably pertaining to medical and healthcare services in conformance with
RHG, to services provided to Qualified Participants, the standards for his/her specialty as established by
arid. to Physician's performance under . this the applicable specialty board and the local/regional
Agreement. Physician Ruther agrees to allow RHG, medical community. Physician agrees that he/she
Payor (with the exception of Qualified Participants shall not engage. in any acts of moral turpitude, as
in the Medical Access Savings Card Program), or a determined by RHG in good faith. Physician agrees
Page 4 of 11 RHG Physician Agreement.doc
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that, to the extent feasible,.he/she shall utilize such III.3 Credentialing. RHG will perform and/or
additional allied health and other qualified personnel delegate to qualified organizations credentialing of
as are available and appropriate for the effective and each Physician to be included under this Agreement.
efficient delivery of care. Physician shall ensure that Credentialing may .include verification-. of all
all such personnel are properly licensed and/or information and documents provided in the
possess the necessary credentials to render the application for participation and investigation of
services that they perform. Physicians education, training and practice history,
including but not limited to queries to the National
II.12 Right to Use Physician's Name. . Physician Practitioners Data Bank and current and previous
agrees to allow RAG to list Physician's name, professional liability carriers, Medicare and
specialty, address and telephone number and other Medicaid.
relevant information in a Member Provider directory
or other materials to help promote and solicit IIIA Operational Functions. RHG shall assign. a
contracts with Payors.. Physician agrees not to use designated representative to be a liaison ,with the
RHG's trademarks or trade .names without RHG's Physicians and Payors, with the exception' of
prior written consent. y _ ::.,... Qualified Participants.in the Medical Access Savings
Card Program, to devote reasonable time and effort
II.13 Noncompliance. Physician understands that to perform RHG's responsibilities hereunder. RHG
his/her failure, to comply with any of the shall arrange, for claims processing except for
requirements imposed on him/her pursuant to this Qualified Participants in the Medical Access Savings
Agreement may result in corrective action .or Card Program.
termination of this Agreement by RHG. ,
IV. REIMBURSEMENT,CLAIMS
11.14 Antitrust Guidelines. Physician agrees to SUBMISSION AND PAYMENT
comply with.all antitrust guidelines and procedures
promulgated by Federal and State entities and RAG IV.1 Reimbursement.RHG shall arrange for Payors
from time to time. to pay Physician the reimbursement: rates for
services..rendered to Qualified Participants pursuant
III_. RHG's.OBLIGATIONS to Exhibit B. Physician agrees and acknowledges
that RHG. is acting solely. in an administrative
111.1 Marketing to Payors. RHG shall enter into capacity in providing a network of quality health
agreements with Payors; implement systems to services. .RAG is not theclaims paying agent and
respond to Payors, Customers. and Member will notbe liable for the payment of any amount
Providers requests for information; provide owed by a Payor to Physician in the event that
clarification of policies concerning the operation of Physician is unable to collect such amount of
Plans or Programs, as defined by Payor Agreements; money,
and assist Member Providers to obtain information
or clarification regarding the. Plans or Programs. IV.2 Reimbursement Rates. Physician is to be paid
Physician agrees to work in cooperation with RHG . by the Payor according to the rates established in'
to market the services of the Member Providers to Exhibit B. Physician hereby agrees that rates in
Payors. Exhibit B,which niay be amended from time to time
upon mutual agreement, represent-the total amount. .
111.2 Utilization Review and Quality Assurance to be received and agrees to look solely to the Payor
Programs. Payor with the exception of Qualified for payment for such services. Payment will be.
Participants in the Medical Access Savings Card made for healthcare services actually rendered. For
Program or RHG may establish Utilization Review services rendered to Qualified Participants of the .
and Quality Assurance Programs. Such programs Medical Access Savings Card Program, Physician
shall be in accordance with the Standards and can and should make payment arrangements prior to
Guidelines established by RHG as outlined in the delivery of care directly with the patient or
Exhibit A,which may be amended from time to time responsible .party. Services provided under the
upon written notice to Physician. provisions of the Medical Access Savings Card
Program must be documented by a receipt that the
Page 5 of 11 RHG Physician Ageement.doc
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Qualified Participant may use for tax purposes or in responsible for payment for services deemed not to
conjunction with other coverage. Physician can be a covered service by RHG or.its designee unless,
pursue collection efforts directly with Qualified prior to providing such services, the Qualified
Participants of the Medical Access Savings Card Participant has been informed that (i) the.services(s)
Program, if necessary. All others will be paid,when to be provided are not.covered, and (ii) that the
appropriate, only after submission of a complete and Payor with the exception of Qualified Participants in.
accurate claim. RHG does not guarantee and makes the Medical Access Savings Card Program, will not
no guarantees, representations, .warranties or pay for such services, and (iii) that.the Qualified
covenants regarding the selection or use of Participant will be financially liable• for such
Physician's services by any Qualified Participant or services, and (iv) the Qualified Participant
Payor, or the number of patients, if any, which may voluntarily agrees, in writing, to pay .for such-
result from participation in RHG's provider network. services:.When Qualified Participant is covered by.a
The obligation of.a Payor to reimburse Physician in state or federally regulated 'occupational injury and
accordance with Exhibit B for the provision of illness program, Physician agrees to comply with
services to a Qualified Participant shall'. be state and federal regulations regarding .holding
conditioned..upon.a.good faith determination by the _ Qualified Participants_harmless for amounts not paid
Payor or its designated representative that (i) by Payor for any reason, including Payors:
Physician is in compliance with the Payor's insolvency.
utilization management program, and (ii) such
services . are medically necessary, whether_ such IV,5 Payment• of Claims. RHG shall
determinations .are made before, on or after the administratively arrange for. the Payor or its
provision of services to such Qualified Participant. designated representative to pay undisputed claims
which are accurate, complete and comply with the
IV.3 Claim Forms, Claim forms are required for all. Agreement within the shorter of(i) the time period.
services :with the 'exception of services provided. mandated by state law, or (ii) the .time period
under the provisions of the Medical Access Savings established bythe applicable Payor Agreement,
Card Program. All claims must be submitted
complete and accurate on HCFA 1500 and in the IV.6 Erroneous Payment. m the event that a Payor,
manner designated by RHG and must include billed and/or its designated representative pays, the
charges(not discounted rates)and appropriate codes, Physician (i) more than once, or (ii) -an incorrect
consistent with policies established or approved by amount, or (iii) an overpayment, the Payor or its
RHG or the applicable state regulations. All claims designated representative may,.at its sole option and
must be submitted within thirty (30) days, or within discretion, request the return of such amount from
such time period from the date of service, or as Physician. -
specified by RHG or its designee. In the event that
Physician is unable to submit a claim in accordance IV.7 Copayment/Coinsurance: Physician may
with this Section IV.3, as a result of factors not directly bill a Qualified Participant (excluding
within Physician's reasonable control, Physician occupational injuries and illnesses and the Medical
shall notify RHG. in writing of the. cause of Access Savings Card) for copayments, coinsurance
Physician's inability to submit the claim and RHG and deductibles,.but payment.for such copayments,
!nay, but shall not be required to, waive the coinsurance and deductibles shall be in accordance
provisions of this Section IV.3.. with the amounts set forth in the applicable benefit
IVA Limited Recourse Against Qualified plana Physician may directly bill and collect from.a.
Participants. Except as otherwise provided in this _.Qualified .Participant- at _Physician's usual and
Agreement (Section I.9), Physician agrees to seek customary charges' for any Qualified. Participant
payment from each Payor for services provided to its approved services rendered which are not Covered
Qualified Participants, and agrees that he/she will Services. Neither the.Participating Payors nor RHG
not seek additional payments or reimbursement from shall have any liability or responsibility,to Physician
Qualified Participants. In addition,Physician agrees for these charges.
that neither RHG, the Payor nor the Qualified
Participant shall be billed or ultimately held
Page 6 of 11 RHdPhysician Agreement.doc .
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V. HOSPITAL_/FACILITY ADMISSIONS claim and to cause their insurers to do likewise.
However, RHG shall have the right to take any and
If a Qualified Participant requires a non-emergency all actions they believe necessary ,to protect their
hospital/facility, admission by Physician, Physician interest. -
shall verify the patient's status as a Qualified
Participant, arrange for admission with a Member VI.3 Indemnification of Physician. Physician will be
Provider and, if required by RHG or the Payor, responsible for its own acts or omissions and any
secure authorization for such admission prior to the and all claims, liabilities,injuries; suits and demands
admission in accordance with the applicable and expenses of all kinds which may result or arise
Utilization Review and Quality Assurance Program. out-of any alleged malfeasance or neglect caused or
Medical Access Savings Card Program Participants alleged to have be caused by: its employees or
do not require pre-certification, authorization or representatives, in the performance or omission of
utilization management forhospital/facility any act or responsibility under this Agreement. In,
admission. For all other Qualified Participants a the event that a claim is made against Physician, it is
Physician who does not.secure the required prior the intent of Physician to cooperate in the defense of.
authorization or comply with continuing stay.review-._,. _ said claim and,to cause,their insurers to do likewise.
processes under.the applicable Utilization Review However, Physician shall have the right to take any -
and Quality Assurance Program, may be denied and all actions they believe necessary to protect their
payment for professional services associated with interest.
the Qualified Participant's admission. Finally,
Physician agrees to cooperate and participate in a VII. TERM AND TERMINATION
coordinated discharge planning program as may be
established by RHG or applicable Payor. VII.l . Term. The term of this Agreement shall be
for one (1)year from the:date hereof and shall be
VI.'INSURANCE AND INDEMNIFICATION automatically .renewed on an annual basis for
successive twelve(12)month periods,unless sooner_
VI.I.Insurance Requirement.Physician shall provide terminated in accordance with Section VII.2.
and maintain such policies of professional liability
insurance, in a form and with insurance carriers VII.2 Termination. This Agreement may be
acceptable to RHG. The amounts and extent of such terminated sooner on the first to occur of the
insurance coverage shall be in the .amounts following; .
determined by community standards for relevant
specialties and shall be subject to the approval from VII.2.1 Termination by Physician. Physician may
time to time of RHG. If such coverage is under a terminate this Agreement in the event of a material.
"claims-made" policy, Physician agrees to provide default or breach of RHG's obligations hereunder,
and maintain such insurance .coverage or a "tail" upon thirty (30) days prior written notice and the
policy in the same amounts following the failure of RHG to cure such breach or default within
termination of this Agreement. �Physician shall such thirty(30) day period. In addition, in the event_
promptly demonstrate evidence of insurability and of an "emergency situation", Physician. may `
that the required insurance is paid and in force upon terminate the Agreement upon thirty(30) days prior
request of RHG. written notice and the acknowledgment by RHG that
such an emergency condition does exist.
VI.2 Indemnification -of RHG. RHG. will be "Emergency Situation" shall mean an unforeseeable
responsible for its own acts.or omissions and any event,not resulting from Physician's act or.omission,
and all claims,liabilities, injuries, suits.and demands which materially affects, Physician's. ability to
and expenses of all kinds which may result or arise continue the practice of medicine or to perform his
out of any alleged malfeasance or neglect caused or obligations hereunder.
alleged to have be caused by its. employees or
representatives;_ in the performance or omission of VII.2.2 Termination by RHG. A Member.Provider
any act or responsibility under this,Agreement. In shall automatically be.telminated on the date when;
the event that a claim is made against RHG, it is the (i) Physician's license to practice medicine or other
intent of RHG to cooperate in the defense of said licensed healthcare profession in the state where
Page 7 of 11 `RHO Physician Agreement.doc
_ 12/05/01
services are rendered, is suspended or revoked, (ii) VII.3 Effects of Termination. Upon termination of
Physician's medical staff privileges at a participating this Agreement, neither party shall have any further
facility are revoked- or suspended, unless such obligation hereunder except for (i) obligations
Physician's privileges are reinstated within twenty accruing prior to the date of termination, including
(20) days of such suspension, (iii) Physician's DEA without limitation, any.obligation by Physician to
or applicable. State Controlled . Substance continue to provide healthcare services to Qualified .
Registration number required by Section II.6 above Participants, and (ii)obligations, promises or,
is suspended or,revoked, unless such Physician can covenants contained herein which are expressly
arrange for other Member Providers to prescribe made to extend beyond the term of this Agreement.
regulated drugs for Qualified Participants under the
care of Physician within ten(10)days of such loss of VIIA Qualified Participant and Payor Notification.
such Registration number(s) and gives RHG notice Upon the termination of this Agreement, by either
of the same, (iv) Physician is excluded from party, Physician shall cooperate with RHG to notify
participation in the Medicaid or Medicare programs, Payors, and Qualified Participants of such
(v) Physician loses or experiences a material termination.
reduction_in,,malpractice insurance,..(vi) Physician _. ._ . . _.
engages in any act, omission; demeanor or conduct VIII. CONTINUATION OF BENEFITS
that is reasonably likely to be detrimental to patient
safety or to the delivery of quality patient care, or to VIII.1 Continuation of Benefits. Except for Medical
lead to the provision of professional.services below Access Savings. Card Program Participants, upon
applicable professional standards, or (vii) Physician termination of this Agreement, Physician shall
is convicted of a Felony, (viii) Physician is found incontinue to provide services in accordance with this
violation of professional conduct, or(ix) thirty(30) Agreement to any Qualified Participant currently
days following written notice by RHG of a material undergoing treatment by Physician.until wr eedically
default or.breach by Physician hereunder and the appropriate transfer of care has been accomplished
failure of Physician to cure such default or breach provided,however,that.Physician shall exercise best.
during such thirty(30)day period. efforts to accomplish such transfer withimthirty(30)
days after the -date this 'Agreement. terminates..
VII.2.3 Termination for Insolvency, This Agreement Physician shall be reimbursed for any such services
shall terminate immediately in the event.that either in accordance with the terms of this Agreement.
RHG or Physician: voluntarily or involuntarily,
liquidates, dissolves or becomes subject to any VITI.2 Survival. The provisions of this Article VIII
proceeding for the rehabilitation or conservation of shall survive the termination of this. Agreement
their financial affairs. regardless of the cause giving rise to such _
termination, as will sections II 8, VI.2, VI.3, VII.3,
VII.2.4 Termination by Either Party. Either party IX, and X, The .provisions of this Article.VIII
may terminate this Agreement without cause upon supersede any oral or written agreement to .the
one hundred twenty(120)days prior written notice. contrary now existing or hereafter entered into
between Physician and any Qualified Participant or
VII.2,5 Unforeseen Events. In the event that either any person acting on a Qualified Participant's behalf.
party's ability to perform their obligations under this
Agreement is substantially interrupted,by war, fire, IX. CONFIDENTIALITY
insurrection, riots, the elements, earthquake, acts of
God, or other similar circumstances, beyond the All business, medical and.other records relating to
reasonable control of such party, the party shall be the operation of RHG, including, but not limited to,'
relieved of those obligations for the duration`of the books of account, general administrative records,.
interruption upon notice to the other party. In the policies and procedures, pricing information, terms
event that the interruption'is reasonably determined of this Agreement and all information generated
likely to persist for at least ninety (90) days,either and/or contained in management information
party may terminate this Agreement upon thirty(30) systems owned by or pertaining to RHG, and all
days prior written notice. systems, manuals, computer software and other
materials, but excluding patient charts, shall be.and
Page S of 11 RHG Physician Agreement.doe
12/05/01..
remain the sole-property of RHO (collectively, the X.2 Non-Exclusivity. Nothing-in this Agreement
"ConfidentialInformation"). Physician shall be construed to restrict the Physician'or RHO
acknowledges that the Confidential Information and from entering into other contracts or agreements to
all other information regarding RHO, that is provide healthcare services to Payors _or other
competitively sensitive, is the property of RHO and healthcare delivery plans, patients, and employer
RHO may be damaged if such information was groups:
revealed to ,a third party: Accordingly, Physician
agrees to keep strictly confidential and to hold in X.3 Entire Agreement: This Agreement contains
trust all Confidential Information. Upon termination the entire understanding of the parties and
of this Agreement by either party for any reason supersedes any prior understandings and agreements;
whatsoever,Physician shall promptly return to RHO written or oral, respecting the subjects discussed
all material constituting Confidential Information or herein.
containing Confidential Information; and Physician X.4 No Waiver. The waiver by either party of a
will not thereafter use, appropriate,. or reproduce breach, or violation of any provision:. of this
such information or disclose such information to any Agreement shall not operate as or be construed to be
third party.—Physician.specifically agrees that_under.. a.wadyor of any..subsequent breach hereof.
no circumstances will Physician discuss the terms
and conditions of this Agreement, and in particular X.5 Regulatory Compliance, -Physician and RHO.
the pricing information herein, with any. Member agree that each shall comply with all applicable
Provider, healthcare provider or purchaser of requirements of municipal, county, state and federal
healthcare services. authorities, all municipal and county ordinances and
regulations, and all applicable state and federal
X. MISCELLANEOUS statutes and regulations, now or hereafter-in force
and effect, governing RHO, Physician the provision.
X.1. Disputes. All disputes and differences between of services of by a Physician, 'and/or Payors;
the Physician and RHO upon which an amicable including but not limited to applicable requirements
understanding cannot be reached are to be decided under any state or federal fair employment practices,.
by the following method: equal employment opportunity, or similar laws
declaring discrimination in'employment based upon
X.1.l Mediation through RHO. The Physician shall race, color,creed, religion; sex; or national origin as
notify RHO. in writing of the dispute or illegal, and,Titles VI and VII of the Civil Rights Act
disagreement, he/she shall supply RHO with all of 1964, Section 202 of Executive.Order 11246 as
pertinent information and state his/her position on amended by Executive Order 11375, Sections 503
the dispute. Upon receipt of this information, RHO ' and 504 or the Rehabilitation Act of 1973 and Title
will immediately contact Payor and require the same IV° of the Vietnam Era Veterans Readjustment
information. RHO will then attempt to mediate the Assistance Act of 1974, and Sections 1 and 3 of
dispute to the mutual satisfaction of all parties. If Executive Order 11625, or any applicable rule or
mediation is not possible within a reasonable time, regulation promulgated pursuant to any such laws:or
not to exceed thirty.(30) days from the time of first orders.
notice,the following procedure will apply;
X.6 Governing. Law. This Agreement shall be
X.1.2 Arbitration. If the dispute cannot be solved by governed by and construed. in accordance with
the mediation process described above, either the applicable Texas State law.
Physician, RHO or Payor may elect to submit the .
dispute to binding arbitration under the rules of the ~ X.7. Amendments: This Agreement may be
American.Arbitration. Association or any other amended ,by RHO upon thirty (30):days written .
method of arbitration mutually agreed upon by the notice of such proposed amendment. Failure.- of
parties. Arbitration will be conducted in Houston, Physician to provide written objection to such
Texas. Each party will be responsible for their own " amendment within the thirty (30) day period shall
legal fees. The cost of the arbitration services will constitute Physician's approval of such amendment.
be the sole responsibility of the party requesting the
arbitration.
Page 9 of 11 RHO Physician Agreement.doe.
12/05/01
X.8 Severability. The invalidity or un-enforceability Physician or Representative/Designee: (Please Print)
of any term or condition hereof shall in no way
affect the validity or enforceability of any other term Name: (Y nk&iL. 1+/ um KE lorneC
or provision. p
Organization: O R. R i cynayd 61 e'nke
X.9 Assignment. Physician may not assign or
otherwise transfer any right or delegate any duty of Address: I bQ5j I LLKYJ Fyetwc2m 3rdq
performance hereunder, in whole or in part without
the prior written consent of RHG. RHG retains the City/State/Zip: G,-C) TX '1(o U A
right to assign this Agreement,in whole or in part,to
any entity with which RHG-or its parent company or Telephone: C)
any of its subsidiaries is affiliated, or with which it
merges or consolidates. Fax: girl-5'71 - JC A 8a+
X.10 Third Party Beneficiaries. Except for Payors Organization:
and the agents .thereof,_.there-are..A_o third .party..... -.__. . . _...._. _ . . _:Rockport.Healthcare Group,Inc.
beneficiariesof this Agreement. Attn: Director of Provider Relations
50 Briar Hollow Lane, Suite 515W
X.11 Captions. The captions and headings Houston, TX 77027
contained in this Agreement are for reference Telephone: (713) 621-9424
purposes only and shall .not affect in anyway the Fax: (713) 621-9511
meaning or interpretation of this Agreement.
or to such other address, and to the attentionof such
X.12 Execution of Counterparts. This Agreement other person(s) or officer(s) as either party.'may
may be executed in any number of counterparts, designate by written notice.
including facsimiles, each of which shall be deemed
to.be an original as against any part whose signature
appears thereon, and all of. which shall together
constitute one and the same instrument.
X.13 Partial Invalidity. If any part, clause or
provision of this Agreement is held to be void by a
court of competent jurisdiction, the remaining
provisions of this Agreement shall not be affected
and shall be given construction,_if possible, as to
permit it to comply with the minimum requirements
of any applicable law, and the intent of parties
hereto.
X.14 Official Notices. Any notice or communication
required,.permitted or desired to be given hereunder
shall be deemed effectively given when personally
delivered or mailed, return receipt requested, or
overnight express mail addressed as follows:
Page 10 of 1 I RHG Physician Agreement7doc
12/05/01
IN WITNESS WHEREOF, the undersigned will be
deemed to have executed this Agreement as of the
date this Agreement is signed by RHG.
For and on behalf of: For and on behalf of:
Rockport Healthcare Group,Inc. Physician or Representative/Designee
50 Briar Hollow Lane, Suite 515W ,-
Houston,TX 77027 SignatureV/ -O�t
Name: i awd F 14 af.ADb
Mark C.Neer (Print)
Sr.Vice President.Busbjess De v 4ment TIN: ��
Date: Date: &I;- .
r
Page 11 of 11 RHG PhysicianAgreementA0c
12/05/01
EXHIBIT A
STANDARDS AND GUIDELINES FOR PAYORS'
UTILIZATION REVIEW AND:QUALITY ASSURANCE PROGRAMS
ROCKPORT HEALTHCARE GROUP,INC. (RHG)
Each.Accident and Health, Occupational Injury and Illness, Personal Injury Protection,Payor or RHG may have
or may establish a Utilization Review and Quality Assurance Program for its Qualified Participants. Medical
Access Savings Card Program Participants do not fall under any Utilization Guidelines. All other Payors or.
RHG may designate a utilization review organization to conduct the utilization review and case management of
healthcare services under such Utilization Review and Quality.Assurance Program.
RHG shall review each Payor's,with the exception of Qualified Participants in the Medical Access Savings Card
Program,Utilization Review and Quality Assurance.Pro gram in accordance with RHG's Standards and Guidelines .
for Payors' Utilization Review and Quality Assurance Programs asr described.in this Exhibit. Physician and/or
Member Provider agrees to comply-and be bound by such program in accordance with Article II of. this,
Agreement.
Such Standards and Guidelines for Utilization Review Programs may be amended from time to time upon written
notice to Physician and/or Member Provider.
The primary goals of the Utilization Review Programs shall be to:
1) Ensure and certify for the payment of benefits that healthcare services meet the definition of medical
necessity as defined by the Payor or the Payors designee;
2) Ensure that healthcare services are provided at the appropriate level of care; and
- 3) . Ensure that healthcare services meet local community standards for quality of care.
Utilization Review Programs may include one or more of the following components:
1) Pre-Admission/Prospective Review of elective admissions for all inpatient and ambulatory surgical
services.
2) Post-Admission Review of emergency and urgent inpatient admissions.
.3) Admission and/or.Concurrent Review of all inpatient stays. Concurrentreviews.may include periodic
reviews and certification of treatment plans.
4) Continued Stay Review of all inpatient cases when the proposed length-of-stay exceeds that which was
initially certified by reviewers of the applicable Utilization Review Program.
5) Retrospective Review ofinpatient and ambulatory surgical cases.
6) Outpatient Certification of certain outpatient services prior to rendering such services,as determined by
the applicable Plan.
(continued on next page) . .
Page 1 of 2 RHG Exhibit A.doc
EXHIBIT A
(continued)
PREADMISSION/PROSPECTIVE REVIEW The Physician and/or Member Provider shall notify the.designated..:
utilization review organization for all elective hospital inpatient, day surgery (hospital, free. standing facility,
office-based), and short stay admissions. The Physician and/or Member Provider is responsible for providing the
designated utilization review organization with the necessary pre-admission information. Whenever possible
Physician and/or Member Provider will do, or cause to have done, pre-admission 'testing when Qualified.
Participant is to.be..hospitalized. Unless otherwise approved in writing by RHG or Payor any Qualified
Participant requiring any elective surgical procedure shall have such surgery performed on day of admission to
the facility(hospital or surgery center). The following information is required:
(a) Pat'ient's name, age, sex,and date of birth,-
(b)
irth;(b) Qualified Participant's name,address, social security number;
(c)-Name of Payor;
(d) Diagnosis(ICD-9 code)and Procedure(CPT code)if applicable;
(e) Name,address,and telepf one`number of the Admitting Physician and/or Member Provider;
(f) Name, address,telephone number of the Hospital or Facility;
(g) Date of service(admission and/or procedure date); and
(h) Admit type:Emergency, Scheduled,Urgent,Psychiatric.
After obtaining the information and determining that theadmission is medically necessary, the .designated
utilization review organization shall provide the admitting Physician and/or Member Provider; with .a.-
certification/authorization and/or case number.
If the Physician and/or Member Provider has not received notice of a pre-admission determination at the time of a
scheduled admission, including ambulatory surgery,the Physician and/or Member Provider shall contact.the
designated utilization review organization to request the determination.
Claims/Cases which are subject to retrospective review and-potential denial of payment include but are not
limited to the following:
• Any admission that was not pre-certified prior to admission or within the Payor specified time frame
for emergency admissions;
• Any service that required pre-certification prior to the provision of such.service which was not pre-
certified; and
Services which are determined not to be medically necessary.
SECOND OPINION When a second opinion is required,the Physician and/or Member Provider shall provide the
second opinion Physician and/or Member Provider with the necessary information to evaluate the patient and to
minimize duplication of services.
CONCURRENT REVIEW Throughout the hospital stay,the attending Physician and/or Member Provider shall
provide the necessary information to substantiate the need for treatment and continued stay. .
The Member Provider, Physician or Qualified Participant may appeal a utilization review determination by.
notifying the utilization review organization that did the initial review. Such requests shall be made in accordance
with the Payor's Utilization Review Program's appeal process and shall contain documentation justifying a
reconsideration. Final decisions on payment determination shall reside with the Payor.
Page 2 oft. RHG ExhibitA,doc'
EXHIBIT B
Reimbursement Schedule ~'J
I. Newton Healthcare Network-Accident &Health; Personal Injury Protection (PIP);
Passport; Medical Access Savings Card (FS )
Provider fees for the programs Iisted above shall be reimbursed at the following: e
80% (eighty percent)of billed charges.
"BR" (By Report), "RNE" (Relativity Not Established), HCPCS (Health Care Financing Administrations Common.
Procedure Coding System)and any unlisted procedure code will be paid at 80%(eighty percent)of billed charges.
Coverage: Coverage for all procedures on the fee schedule are subject to the terms and conditions of the applicable Benefit Plans
and/or the provisions of the Medical Access Savings Card Program.
II.Rockport Community Network-Occupational Injury and IIlness (FS )
„Provider fees for the programs listed above shall be reimbursed at the following:
States with mandated fee schedules-A11 fees will be reimbursed at 85. (eighty five percent)of the state's mandated fees,rules
~ and regulations or usual and customary allowables.
The following Will be reimbursed at 100% of the specified allowable:
Designated Doctor;Maximum Medical Improvement and/or Impairment Rating(99456) .
Required Medical Examination(RME)(99499)
Initial Medical Report(TWCC Form 73)(99080-73)
Report of Medical Evaluation(TWCC Form 69)(99080-69)
'!BR" (By Report),"RNE" (Relativity Not Established),"HCPCS" (Health Care Financing Administrations Common
Procedure Coding System), "DOP" (Documentation of Procedure)and any unlisted procedure code will be paid at 85%
(eighty five percent)of usual and customary allowable.
Coverage: . Coverage. for all procedures on the fee schedule is subject to the terms and conditions of the applicable
Occupational Injury or Illness Benefit Plan.
Schedule: Schedule 1I shall apply to the applicable state mandated fee schedule, rules and regulations and will update
accordingly and in conjunction with the same,.
I/We accept the fees as outlined in this Exhibit B.
For and on behalf of: For and on behalf of:
(Name,address,etc.)
ROCKPORT HEALTHCARE GROUP,INC. Ic1 R I ( hcurd F 46M k
50 Briar Hollow Lane,Suite 515W 1`3U6 Rlroo f1"P.tlt1)PL;ta suA tt 3 `r.
Houston,Texas 7702 -160-01
Signature
Mark C.Neer Printed Name ►(+)/.j KIS
Sr.Vice President,Busine Devel meat Title
Date
TIN 7 g Yo Date
121401 . Page I of I
12/19/01
2015RHG.doe